Provider Demographics
NPI:1346377850
Name:SHAW, MARC D (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:D
Last Name:SHAW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7965 HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9703
Mailing Address - Country:US
Mailing Address - Phone:831-336-2279
Mailing Address - Fax:
Practice Address - Street 1:7965 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:BEN LOMOND
Practice Address - State:CA
Practice Address - Zip Code:95005-9703
Practice Address - Country:US
Practice Address - Phone:831-336-2279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6801T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0005490Medicaid
CA810673636OtherBLUE CROSS
CA5480310001Medicare NSC
CASD0068010Medicare PIN
CAGR0005490Medicaid